A study presented at the 2015 Annual Meeting found that the use of liposomal bupivacaine to prevent pain following total joint arthroplasty (TJA) resulted in a significant reduction in opioid consumption and yielded a lower overall cost per episode of care than several other modalities.

Bryan D. Springer, MD, who presented the study, said the findings demonstrate the need to look at an entire episode of care, rather than individual cost centers, when assessing the value of an intervention. Although the addition of a liposomal bupivacaine nerve block will incur a significant expense to the hospital pharmacy budget, it can reduce overall costs and yield several benefits.

Dr. Springer, of OrthoCarolina Hip and Knee Center, and colleagues first conducted a small (58 patients) retrospective pilot study comparing the use of liposomal bupivacaine with single-shot sciatic nerve blocks for total knee arthroplasty (TKA) and single-shot lumbar plexus blocks for total hip arthroplasty (THA). The use of liposomal bupivacaine resulted in equivalent pain control and opioid consumption compared with the peripheral nerve blocks and yielded statistically better resting pain scores in the TKA patients and better resting and 12-hours-postoperative pain scores in the THA group.

Additionally, the average total hospital charges were lower in the liposomal bupivacaine group versus peripheral nerve block for both TKA ($55,548 vs. $58,222) and THA ($52,810 vs. $55,935).

Extended pain control

The advantage of liposomal bupivacaine over standard bupivacaine is the slow release of the local anesthetic from vesicular liposomes into the tissue over a 72-hour period. Dr. Springer explained that liposomal bupivacaine is introduced into the soft tissue at the surgical site. He said that studies have shown positive benefits from its use in both general and foot and ankle surgeries.

Based on the results of the pilot study, the authors conducted a larger comparative analysis of commonly used perioperative pain modalities. They evaluated 366 patients undergoing primary THA or TKA to determine the effect of the following different modalities:

• continuous femoral nerve blocks
• indwelling epidural anesthesia
• elastomeric pumps
• single-shot femoral/sciatic nerve blocks
• liposomal bupivacaine

Each surgeon used one of the five modalities as part of their multimodal pain protocol. Each surgeon was then asked to replace that modality with liposomal bupivacaine. “To minimize bias and focus on the effect of liposomal bupivacaine, no other postoperative analgesic care plans were modified,” saidDr. Springer. “Each surgeon completed injection technique training to control for injection technique variability. We then case-matched cases for each surgeon within the immediate time period with the prior modality.”

Anesthesia charges were not included. Only epidural catheters had lower overall costs per episode. Compared to all other modalities, the use of liposomal bupivacaine resulted in a statistically significant lower consumption of opioids (P = 0.0035).

Although not included in the analysis, the expanded use of liposomal bupivacaine appeared to offer the following “soft” benefits:

• a “dramatic reduction” in patient falls and rapid response calls on the nursing floor
• the elimination of knee immobilizers for TKA patients
• the implementation of a mobilization protocol on day of surgery for TJA patients
• the reallocation of the block nurse in the anesthesia preoperative area

Outside the silo
Although the extended release of liposomal bupivacaine provides improved pain relief for up to 72 hours compared to standard bupivacaine, it costs considerably more. “The rapid adoption of liposomal bupivacaine therefore can have a significant impact on the hospital pharmacy budget when viewed solely within its silo,” he said.

The authors state that the overall value of this modality should be recognized, particularly in light of the lower overall treatment costs and therapeutic benefits seen in this study. “With the focus in health care shifting from volume to value and an evaluation of an entire episode of care, the rigid silo mentality must also change,” they asserted. “This must include the ability to embrace and drive change throughout the hospital rather than just one’s own individual unit and budget. Consideration should now be given to the care provided beyond the pharmaceutical expense and attempts made to identify and support strategic growth areas by data mining, analysis, and application of new cost modalities in which patients, providers, and payers can choose.”

Dr. Springer said that because different surgeons used different surgical modalities, other variables may account for the lower cost with liposomal bupivacaine. Also, the pain protocols were not standardized among surgeons; therefore, differences in the pain regimes used, although all multimodal in nature, could account for differences in the amounts of opioids consumed. “However, protocols among surgeons were not changed, except for the substitution of one modality for the liposomal bupivacaine,” the authors wrote.

“We believe that placing emphasis on an episode of care to evaluate the introduction of new and potentially more expensive modalities is critical, as opposed to focusing on their effect on just one silo of care,” they concluded. “Our data would suggest that by doing so, we can assess the true value of a modality in lowering cost and improving outcomes. When evaluating the entire episode of care, the addition of liposomal bupivacaine resulted in less overall cost per episode of care and decreased opioid consumption compared to other commonly used modalities in total joint arthroplasty.”

Coauthors with Dr. Springer are Eugene P. Christian, MD, and Susan Bear, PharmD.

One or more of the authors reported potential conflicts of interest. The most current disclosure information may be accessed electronically at www.aaos.org/disclosure

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

• Liposomal bupivacaine provides depot delivery of bupivacaine with infiltration into the soft tissue at a surgical site and slow release of the local anesthetic into the tissue over a 72-hour period.
• This study compared results from the use of liposomal bupivacaine in total joint arthroplasty with those of four commonly used perioperative pain modalities.
• The group receiving liposomal bupivacaine demonstrated a significant reduction in opioid consumption and a lower overall cost per episode of care than several other modalities.
• Although the use of liposomal bupivacaine incurs a greater pharmacy expense, the value it provides in terms of reduced overall cost and opioid consumption, along with possible therapeutic benefit, warrants its consideration in total joint arthroplasty.